Temporary Underground Service Form
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1Temporary Underground Service (TUG)
06/03
TO:
Growth & Resource Management
Date__________________________________________
Permit Center
123 W. Indiana Ave., Room 203
DeLand, Florida 32720-4253
Permit No._____________________________________
**ALL FEES MUST BE PAID RELATED TO THIS BUILDING PERMIT**
Building Identification ____________________________________________________________________________________________
Address _______________________________________________________________________________________________________
Name of Power Co. ______________________________________________________________________________________________
The reason for this request is as follows: _____________________________________________________________________________
______________________________________________________________________________________________________________
The undersigned understands and agrees that approval of this request does not constitute a waiver of procuring a Certificate of Occupancy
prior to any type of occupancy of this building. Should the building be found occupied without a Certificate of Occupancy having been
issued, The Volusia County Building Official has the right to have the power disconnected.
CONSTRUCTION CONTRATOR
______________________________________ _______________________________ ___________________________
Contractor’s Signature
Contractor’s Name Printed
License Number
STATE OF FLORIDA
COUNTY OF _________________________
Affirmed and subscribed before me this ______ day of __________________ 20____ by ____________________________
who is personally known to me or who has produced _________________________________ (type of ID) as identification.
________________________________________
________________________________________
Signature of Notary Public, State of Florida
Print, Type or Stamp Name of Notary
Notarial Seal
**************************************************************************************************************
OWNER/LEASEHOLDER (If leaseholder; a lease showing at least 29 years must be attached)
________________________________________
________________________________________
Owner’s Signature
Owner’s Name Printed
STATE OF FLORIDA
COUNTY OF ______________________________
Affirmed and subscribed before me this ______ day of ____________________ 20 _____ by ___________________________________
who is personally known to me or who has produced ____________________________________________ (type of ID) as identification.
________________________________________
________________________________________
Signature of Notary Public, State of Florida
Print, Type or Stamp Name of Notary
Notarial Seal
**************************************************************************************************************
ELECTRICAL CONTRACTOR
_______________________________________
_________________________________
_______________________________
Electrician’s Signature
Electrician’s Name Printed
License Number
STATE OF FLORIDA
COUNTY OF _____________________________
Affirmed and subscribed before me this ______ day of __________________ 20_____ by ______________________________________
who is personally known to me or who has produced ____________________________________________ (type of ID) as identification.
________________________________________
________________________________________
Signature of Notary Public, State of Florida
Print, Type or Stamp Name o f Notary
Notarial Seal
***************************************************************************************************************************
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